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Frequently Asked Questions Insurance

Changing Health Plans

Outside of Open Season, you can make changes due to certain events, called qualifying life events (QLEs) The most common QLEs for changing enrollment type or plan are: marriage, acquiring a child, moving away from the area served by your Health Maintenance Organization (HMO), losing health insurance coverage, or changing employment status.

During the annual FEHB Open Season, you may enroll, cancel an enrollment, change plans or options, and waive or begin participation in premium conversion.

If you waived participation in premium conversion, you can change from self- and-family enrollment to a Self Only enrollment or cancel your enrollment at any time. You can make other changes during Open Season or due to certain events. Your Human Resources Office can give you more information about these events.

Open Season changes for most Federal employees are effective the first day of the first full pay period that begins in January. Generally, mid-year changes are effective on the first day of the pay period which begins after your enrollment is received by your Human Resources Office.

Most health maintenance organizations (HMO) restrict enrollment to an area where its doctors and hospitals are accessible. Although some HMOs do not have restrictions on where you live or work, please recognize that if you later find it is inconvenient to get to a plan provider, you may have to wait until the next Open Season to change plans.

“Changes to Federal Benefits Eligibility Due to Health Reform” are now available on OPM’s website at http://www.opm.gov/insure/health/aca/index.asp. These FAQs provide your employees with important information about child eligibility and Federal Benefits under the Affordable Care Act.

FastFacts offering a basic understanding of the Affordable Care Act and child eligibility under the Federal Benefits Health Benefits (FEHB) Program are now available on our website at http://www.opm.gov/insure/fastfacts/reform.pdf. The FastFacts is a two-page document designed to be easily posted to a bulletin board as well as distributed electronically.

If you have specific questions, please contact your agency’s benefits officer. If you do not know who this person is, please go to http://apps.opm.gov/abo/ where you will find a list of agencies and their Headquarters Benefits Officers.

You can change plans during the annual FEHB Open Season and whenever you have a qualifying life events (QLE) -- such as marriage. Becoming aware of another plan that has better benefits, even if you didn't expect to want the extra benefits when you had a chance to change plans before, does not qualify as a "QLE" that allows you to change plans.

The plans print their provider directories and have them available during Open Season. Many plans also provide this information on their websites. If your agency has an Open Season health fair this fall, the plans probably will be there to hand out their brochures and provider directories. You can also call the plan at the number listed in the Guide to Federal Benefits. You can also find specific plan contact information on the FEHB website.

If you disagree with the plan’s decision on your claim, the Federal Employees Health Benefits (FEHB) Program provides for an appeal process. Check your plans FEHB brochure to see if the service is covered, limited, or excluded.

Review and follow the directions in the disputed claims section (Section 8) of the brochure. This section will tell you how to ask the plan to reconsider your claim. You must explain why (in terms of the applicable brochure coverage provisions) you feel the services should be covered.

If the plan again denies the claim, read the plan's decision letter carefully. Then, check your plan's brochure again. If you still disagree with the plan's decision, the disputed claims section of the brochure will tell you how to write to the U.S. Office of Personnel Management to ask us to review the claim.

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